RIDGEFIELD PARK PUBLIC SCHOOLS - SharpSchoolrpps.ss8.sharpschool.com/UserFiles/Servers/Server... ·...

RIDGEFIELD PARK PUBLIC SCHOOLS712 Lincoln Avenue, Ridgefield Park, NJ 07660

201-807-2640 www.rpps.net

INFORMACIÓN SOBRE LA INSCRIPCIÓN

La siguiente es una lista de documentos que deben ser presentados con el fin de inscribir a un estudiante en el sistema de Escuelas Públicas de Ridgefield Park.

Por favor Notar: Todos los elementos que se indican a continuación deben presentarse o no será aceptado su registro.

Solicitud de inscripción (una por estudiante)

Verificación de Información de Emergencia

Certificado de nacimiento, pasaporte o tarjeta de inmigración

Identificación de Padre o Tutor

Afirmación de la residencia (prueba de dirección) –

• Si es un alquiler, incluye el contrato de arrendamiento actual y también una factura de serviciospúblicos. Si usted no tiene un contrato de arrendamiento o escritura en su nombre y estánviviendo con alguien en un apartamento, usted debe completar la declaración jurada delpropietario

• Si usted es dueño de su casa, es necesario incluir el título/escritura o un recibo de la contribuciónactual de los impuestos sobre bienes inmuebles y también la factura de servicios públicos .

Encuesta sobre idiomas

La Tarjeta de Transfiera de la escuela anterior con NJ State ID # (si es aplicable ).

Completadas - formularios médicos:

• Historia de Salud para Estudiantes (completado por el padre / tutor)• Requisitos para los nuevos participantes: inmunización/tarjeta de vacunación y el documentosobre el examen físico (completado por el médico)

* Formulario de Autorización para Liberar Registros- sólo para estudiantes transferidos:

• Registros Generales: Académico , médico, asistencia, disciplina , y las pruebas estandarizadas• Plan de Educación Individualizada (IEP si es aplicable)• Plan 504

Por favor, póngase en contacto con la escuela para hacer una cita.

RIDGEFIELD PARK PUBLIC SCHOOLS 712 Lincoln Avenue, Ridgefield Park, NJ 07660

201-807-2640 www.rpps.net

INFORMACIÓN ADICIONAL REQUERIDA

Los estudiantes de la escuela secundaria (High School) deben proporcionar expedientes académicos (transcripciones) mostrando trabajo del curso escolar, curso anterior y los créditos completado. Si el estudiante está entrando en el noveno grado, se necesita una prueba de que el estudiante haya completado el octavo grado. Si viene de una escuela de Nueva Jersey, por favor proporcione los resultados de los exámenes NJASK y HSPA, si está disponible.

Custodia o tutela - Papeles de la Corte Subrogante de Bergen se deben presentar cuando un estudiante no vive con el padre .

PAOUETE DE BIENVENIDA PARA PADRES - REOUISITOS DE INSCRIPCION

La siguiente evidencia se debe presentar y aprobar antes de que el nifto pueda inscribirse y comenzar a asistir a la escuela: COMPROBANTE DE RESIDENCIA: propietario de la propiedad (propietario) e inquilino de la vivienda. PROPIETAR1O DE VIVIENDA: Hipoteca o escritura, Registro de impuesto a la propiedad que indica Ia

direcci6n de Ridgefield Park. ARRENDADOR DE VIVIENDA: Arrendamiento original actual que verifica nombres, estado o duraci6n de!

arrendamiento. El contrato de alquiler tambien debe mostrar el nombre, la direcci6n y el numero de telefono de! propietario. Una factura de servicios que indica Ia direcci6n de Ridgefield Park.

HISTORIAL MEDICO Debemos asegurar Ia salud, la seguridad y el bienestar de su hijo (y otros niftos) al momento de ingresar y

posteriormente. La asistencia de su hijo puede retrasarse si no puede proporcionar documentaci6n escrita que indique que se ha administrado al menos una dosis de cada una de las siguientes series de vacunas apropiadas para su edad:

a. 2 dosis de vacunas contra el sarampi6n, las paperas y l dosis de varicela (para varicela) administradas despues Primer cumpleaftos (o prueba de un medico de haber tenido una o mas de estas enfermedades).

b. 4 dosis de DPT o DTaP, con una dosis administrada en o despues de! 4to cumpleaftos o 5 dosis. c. 3 dosis de Ia vacuna contra la polio, con una dosis administrada despues de! 4° cumpleaftos o 4

dosis. d. 3 dosis de hepatitis B e. El 6 ° grado y mas alto requieren vacunas Tdap y Meningococcal.

La prueba TB Mantoux con resultados es muy recommendable Formulario de Historial de Salud (pagina 6); Formulario de registro de alergias (pagina 7); Formulario de

medicaci6n (pagina 8); tambien se requiere que este complete Requerido para completar segun corresponda: Registro Universal de Atencion Medica - Grados K-5

Examen fisico para los grados 6-12. REGISTROS ACADEMICOS Debemos determinar el mejor nivel de grado posible y la ubicaci6n de! programa academico para su hijo a partir

de su primer dia de clases. En ausencia de registros academicos completos, Ia ubicaci6n educativa inicial de su hijo puede cambiar en funci6n de Ia recepci6n de Ios registros o como resultado de una evaluaci6n adicional por parte del distrito.

PRUEBA DE EDAD Certificado de nacimiento original con sello en relieve u otra prueba de la identidad del estudiante. Si su hijo actualmente tiene un IEP, debera comunicarse con Ia Oficina de Servicios Especiales al 201-807-

2650.

DECLARACIONE COMPLEMENTARIA. ADICIONALES Se pueden necesitar otras 6rdenes judiciales / 6rdenes de colocaci6n de agencias.

4/23/20

RIDGEFIELD PARK PUBLIC SCHOOLS 712 Lincoln Avenue, Ridgefield Park, New Jersey 07660

(201) 807-2640 / www.rpps.net

http://www.rpps.net/

RIDGEFIELD PARK PUBLIC SCHOOLS Solicitud De Inscripción

# de ID de Estudiante: ______ INFORMACIÓN DEL ESTUDIANTE # de ID del Estado: ______________

Apellido Primer Nombre Segundo Nombre Genero Fecha de Nacimiento M F Mes Dia Año

Ciudad de nacimiento

Estado de Nacimiento:

Pais de Nacimiento: Fecha de entrada a los EU:

Origen étnico: ___Blanco ___Negro (o

Afro-Americano) ____Indio Americano/

Alascano ___Asiático ____Hawaiano/

Isla del Pacifico __________Otro

Etnicidad _______ Hispano o Latino ______No Hispano o Latino Datos de origen étnico se require de todas las escuelas públicas de NJ para la realización de informes estatales y federales.

Residencia Legal: NJ

Calle Cuidad Estado Zip Code

Nombre de escuela anterior Ciudad, Estado Fecha de asistencia

¿Fue alguna vez el estudiante evaluado para los servicios relacionados con la educación especial? _______NO _______SI

Documentación de respaldo (por favor marque lo que corresponda): ______ IEP ______IFSP ______ISP ______ 504

_____ Evaluación ______Nota del Doctor ______Maestro/Escuela de correspondencia ____Otro_______________________

Hermano(s) asistiendo las escuelas públicas de Ridgefield Park

Nombre Escuela Grado Nombre Escuela Grado

1. 2.

3. 4.

INFORMACIÓN DEL PADRE/TUTOR

Padre/Tutor 1 Contacto Primario

Primer Nombre Apellido Relación

Dirección: (Si differente al estudiante)

NJ

Calle Apto Ciudad Estado Zip Code

Teléfono de la

casa: Portador Celular: Teléfono del trabajo:

Email:

Padre/Tutor 2

Primer Nombre Apellido Relación

Dirección: (Si differente al estudiante))

NJ

Calle Apto Ciudad Estado Zip Code

Teléfono de la

casa:

Celular: Teléfono del trabajo:

Email:

Certifico que la información dada por mi es verdadera, soy consciente de que si cualquiera de las declaraciones hechas por mi son falsas, estoy sujeto(a) a castigo bajo la ley.

___________________________________________ ___________________ Firma del padre o tutor Fecha

USO DE LA OFICINA

Escuela: Programa: Código de Entrada:

Fecha de Registración: Fecha de Entrada a la Escuela:

Grado/HR Año/Graduación de la HS:

Fecha de nacimiento verificada:

Residencia Verificada: Formulario Médicos Aprobados por la Enfermera del Colegio: Iniciales Iniciales Iniciales

Celular:

Portador Celular:

4/23/20

AFIRMACIÓN DE LA RESIDENCIA

Fecha:

Yo, por la presente certifico, que yo,_______________________________, soy el padre/tutor legal de (Imprimir nombre del padre o tutor)

Nombre del Niño Edad Grado Nombre del Niño Edad Grado

Certifico además que mi(s) hijo(s) y yo estamos residiendo legalmente en el Parque de la Ciudad de Ridgefield Park en lo siguiente:

Dirección:

Teléfono #:

Los siguientes documentos, que establecen que estamos domiciliados en la ciudad de Ridgefield Park, se han presentado para su verificación.

A. Arrendamiento original, efectivo durante el año escolar actual OrLa participación registrada que muestra la propiedad de una residencia dentro de la ciudad de RidgefieldPark Or Factura/declaración actual del impuesto sobre la propiedad;

YB. Uno de los siguientes documentos adicionales:

Extracto bancario con su dirección (por favor bloquee toda la información monetaria) Factura de servicios públicos o teléfono con su dirección

*Tenga en cuenta que es posible que se requiera documentación adicional*

Afirmo que soy el padre/tutor de los estudiantes que aparecen en este formulario. Además, declaro que este formulario y los documentos adjuntos constituyen una prueba verdadera y precisa de que los estudiantes que figuran en este formulario residen conmigo dentro de la ciudad de Ridgefield Park y continuarán haciéndolo durante el año escolar. Si cualquier estudiante que aparece en este formulario deja de vivir conmigo, o si muevo mi residencia fuera de la ciudad de Ridgefield Park dentro del año escolar, notificaré de inmediato a la Junta de Educación de Ridgefield Park por escrito.

Si se determina que la dirección indicada en este formulario no es mi residencia válida, reconozco que seré responsable de pagar la tasa de matrícula; establecido por el estado de Nueva Jersey, a la Junta de Educación de Ridgefield Park para cada niño que asiste a la escuela en el sistema de escuelas públicas de Ridgefield Park hasta que se haya establecido la residencia.

Certifico que las siguientes declaraciones hechas por mí son verdaderas, soy consciente de que si alguna de las declaraciones anteriores hechas por mí son falsas, estoy sujeto a castigo bajo la ley.

Nombre (impreso) La Firma Fecha


(201) 807-2640 / www.rpps.net

Relationship to child: _______________________________________________



(201) 807-2640 / www.rpps.net

AFIDÁVIT DEL ARRENDADOR (DUEÑO)

ESTADO DE NEW JERSEY

CONDADO DE BERGEN

Yo, ___________________________ de mayor de edad, siendo debidamente juramentado de acuerdo con Ia ley, declaro y digo:

1. Soy el duefio de la propiedad situada en _________ en el Pueblo de Ridgefield Park.

2. ____________________________________ es un arrendatario y ha sido un arrendatario en el sobredicho domiciliedesde el_______ (mes) _____ (afio)

3. Los nombres de los arrendamientos legales son:

Escriba los nombre de todos los adultos y los nifios autorizados para vivir en este domicilio.

Estoy haciendo esta declaración jurada sabiendo que la Junta de Educación de la Ciudad de Ridgefield Park se basará

en lo mismo para determinar si ______________________ será considerado un alumno que tiene derecho a una

educación gratuita.

Firma del Arrendador:

Dirección de Arrendador:

# De Telefono:

Declarado bajo juramento y suscrito en mi

presencia este dia _______ de ________

de __________.

(Notario Público)

1. 5.

2. 6.

3. 7.

4. 8.

4/23/20

4/23/20

MEDICAL HISTORY FORM Today's Date:

Child's Name:

Last name First name Middle name

Child's Age: Date of Birth: / / Cell Phone: Month Day Year

Please complete the child's health history below. Asthma

Yes

No

Date of Diagnosis Treatment and/or Restrictions

Blood Disorder Chicken Pox Diabetes Head Injury

Heart Problem

Seizure

Skin Condition

Speech/Language

Urinary Problem

Vision/Glasses

Allergies: Please complete the ALLERGIES/REACTIONS form in this registration packet.

Current Medications: Please include the name of the medicine, the dosage, time, and reason for use.

Hospitalizations for illness or surgery: Please include diagnosis and year.

I give my permission for this information to be shared with appropriate school staff.

Parent/Guardian Name:

Parent Signature: Date:

Relationship to child


(201) 807-2640 / www.rpps.net


4/23/20

ALLERGY RECORD FORM

Today's Date:

Child's Name: Last name First name Middle name

Child's Age: Date of Birth: / / Cell Phone: Month Day Year

If your child has no allergies/reactions please check here and sign below.

Item Yes No Type of reaction experienced Medication taken Actions to be taken

Dairy Products

Eggs

Peanuts

Other foods: Specify

Bees

Other Animals: Specify

Penicillin

Erythromycin

Other Meds: Specify

Seasonal Allergies Season

Other Allergies: Specify

Comments/ Additional Information:

Parent/Guardian Signature ___________________________________________ Date:

Relationship to child:


(201) 807-2640 / www.rpps.net


4/23/20

MEDICATION FORM

Today's Date: Child's Name: Last name First name Middle name

Child's Age: Date of Birth: / / Cell Phone: Month Day Year Parent/Guardian Name: ____________________________________________________________________

Relationship to Child: ________________________________

A child must not bring to school any prescribed or over-the-counter medication...not one single dose! Any such products must be brought to the school nurse by a parent/guardian with directions for use from a physician. Only a school nurse may administer the medication. By my signature, I certify that my child does not need to take any prescribed or over-the-counter medication during the school day. Parent/Guardian Signature: _________________________________________________________________________ Date There are few exceptions to this rule:

Permission may be granted to your child for self-administration of medication for asthma or other potentially life threatening conditions if the school receives written permission from a parent/guardian and authorization by a physician. Even in this case, we may require that the medication be self-administered in the presence of the school nurse.

By my signature below l give permission for my child to self-administer the medication indicated by the physician. I understand that Ridgefield Park Public Schools shall incur no liability as a result of any injury arising from the self-administration of medication by my child and I shall indemnify and hold harmless the Ridgefield Park Board of Education and its employees and agent against any claims arising as a result of the self-administration of medication by my child.

Parent/Guardian Signature: ______________________________________________________ Date_______________


(201) 807-2640 / www.rpps.net

Diagnosis for which the medication has been prescribed: __________________________________________ Name of medication: ____________________________ Form of medication: _______________________________ Dose: _____________________________________________ Time: _____________________________________________ How soon the dose can be repeated: _________________ List of significant side effects: _____________________ ______________________________________________ Length of time this treatment is recommended: ________

Physician’s Signature and Stamp X: ______________________________________ Physician's Name: ______________________ Address: _____________________________ Tel No.: _________________________________ The above mentioned child has asthma and/or other life threatening

condition and has been instructed in and is capable of self-administering the medication noted above.


■ Preparticipation Physical Evaluation

HISTORY FORM(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep a copy of this form in the chart.)

Date of Exam ___________________________________________________________________________________________________________________

Name __________________________________________________________________________________ Date of birth __________________________

Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Food Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to.

GENERAL QUESTIONS Yes No

1. Has a doctor ever denied or restricted your participation in sports for

any reason?

2. Do you have any ongoing medical conditions? If so, please identify

below: Asthma Anemia Diabetes Infections

Other: _______________________________________________

3. Have you ever spent the night in the hospital?

4. Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU Yes No

5. Have you ever passed out or nearly passed out DURING or

AFTER exercise?

6. Have you ever had discomfort, pain, tightness, or pressure in your

chest during exercise?

7. Does your heart ever race or skip beats (irregular beats) during exercise?

8. Has a doctor ever told you that you have any heart problems? If so,

check all that apply:

High blood pressure A heart murmur

High cholesterol A heart infection

Kawasaki disease Other: _____________________

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG,

echocardiogram)

10. Do you get lightheaded or feel more short of breath than expected

during exercise?

11. Have you ever had an unexplained seizure?

12. Do you get more tired or short of breath more quickly than your friends

during exercise?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No

13. Has any family member or relative died of heart problems or had an

unexpected or unexplained sudden death before age 50 (including

drowning, unexplained car accident, or sudden infant death syndrome)?

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan

syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT

syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic

polymorphic ventricular tachycardia?

15. Does anyone in your family have a heart problem, pacemaker, or

implanted defibrillator?

16. Has anyone in your family had unexplained fainting, unexplained

seizures, or near drowning?

BONE AND JOINT QUESTIONS Yes No

17. Have you ever had an injury to a bone, muscle, ligament, or tendon

that caused you to miss a practice or a game?

18. Have you ever had any broken or fractured bones or dislocated joints?

19. Have you ever had an injury that required x-rays, MRI, CT scan,

injections, therapy, a brace, a cast, or crutches?

20. Have you ever had a stress fracture?

21. Have you ever been told that you have or have you had an x-ray for neck

instability or atlantoaxial instability? (Down syndrome or dwarfism)

22. Do you regularly use a brace, orthotics, or other assistive device?

23. Do you have a bone, muscle, or joint injury that bothers you?

24. Do any of your joints become painful, swollen, feel warm, or look red?

25. Do you have any history of juvenile arthritis or connective tissue disease?

MEDICAL QUESTIONS Yes No

26. Do you cough, wheeze, or have difficulty breathing during or

after exercise?

27. Have you ever used an inhaler or taken asthma medicine?

28. Is there anyone in your family who has asthma?

29. Were you born without or are you missing a kidney, an eye, a testicle

(males), your spleen, or any other organ?

30. Do you have groin pain or a painful bulge or hernia in the groin area?

31. Have you had infectious mononucleosis (mono) within the last month?

32. Do you have any rashes, pressure sores, or other skin problems?

33. Have you had a herpes or MRSA skin infection?

34. Have you ever had a head injury or concussion?

35. Have you ever had a hit or blow to the head that caused confusion,

prolonged headache, or memory problems?

36. Do you have a history of seizure disorder?

37. Do you have headaches with exercise?

38. Have you ever had numbness, tingling, or weakness in your arms or

legs after being hit or falling?

39. Have you ever been unable to move your arms or legs after being hit

or falling?

40. Have you ever become ill while exercising in the heat?

41. Do you get frequent muscle cramps when exercising?

42. Do you or someone in your family have sickle cell trait or disease?

43. Have you had any problems with your eyes or vision?

44. Have you had any eye injuries?

45. Do you wear glasses or contact lenses?

46. Do you wear protective eyewear, such as goggles or a face shield?

47. Do you worry about your weight?

48. Are you trying to or has anyone recommended that you gain or

lose weight?

49. Are you on a special diet or do you avoid certain types of foods?

50. Have you ever had an eating disorder?

51. Do you have any concerns that you would like to discuss with a doctor?

FEMALES ONLY

52. Have you ever had a menstrual period?

53. How old were you when you had your first menstrual period?

54. How many periods have you had in the last 12 months?

Explain “yes” answers here

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of athlete __________________________________________ Signature of parent/guardian ____________________________________________________________ Date _____________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic

Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.HE0503 9-2681/0410

New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71


THE ATHLETE WITH SPECIAL NEEDS:

SUPPLEMENTAL HISTORY FORM

Date of Exam ___________________________________________________________________________________________________________________

Name __________________________________________________________________________________ Date of birth __________________________

Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________

1. Type of disability

2. Date of disability

3. Classification (if available)

4. Cause of disability (birth, disease, accident/trauma, other)

5. List the sports you are interested in playing

Yes No

6. Do you regularly use a brace, assistive device, or prosthetic?

7. Do you use any special brace or assistive device for sports?

8. Do you have any rashes, pressure sores, or any other skin problems?

9. Do you have a hearing loss? Do you use a hearing aid?

10. Do you have a visual impairment?

11. Do you use any special devices for bowel or bladder function?

12. Do you have burning or discomfort when urinating?

13. Have you had autonomic dysreflexia?

14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness?

15. Do you have muscle spasticity?

16. Do you have frequent seizures that cannot be controlled by medication?


Please indicate if you have ever had any of the following.

Yes No

Atlantoaxial instability

X-ray evaluation for atlantoaxial instability

Dislocated joints (more than one)

Easy bleeding

Enlarged spleen

Hepatitis

Osteopenia or osteoporosis

Difficulty controlling bowel

Difficulty controlling bladder

Numbness or tingling in arms or hands

Numbness or tingling in legs or feet

Weakness in arms or hands

Weakness in legs or feet

Recent change in coordination

Recent change in ability to walk

Spina bifida

Latex allergy


I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of athlete __________________________________________ Signature of parent/guardian __________________________________________________________ Date _____________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.



PHYSICAL EXAMINATION FORMName __________________________________________________________________________________ Date of birth __________________________

PHYSICIAN REMINDERS

1. Consider additional questions on more sensitive issues• Do you feel stressed out or under a lot of pressure?• Do you ever feel sad, hopeless, depressed, or anxious?• Do you feel safe at your home or residence?• Have you ever tried cigarettes, chewing tobacco, snuff, or dip?• During the past 30 days, did you use chewing tobacco, snuff, or dip?• Do you drink alcohol or use any other drugs?• Have you ever taken anabolic steroids or used any other performance supplement?• Have you ever taken any supplements to help you gain or lose weight or improve your performance?• Do you wear a seat belt, use a helmet, and use condoms?

2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).

EXAMINATION

Height Weight Male Female

BP / ( / ) Pulse Vision R 20/ L 20/ Corrected Y N

MEDICAL NORMAL ABNORMAL FINDINGS

Appearance

• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,

arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Eyes/ears/nose/throat

• Pupils equal

• Hearing

Lymph nodes

Heart a

• Murmurs (auscultation standing, supine, +/- Valsalva)

• Location of point of maximal impulse (PMI)

Pulses

• Simultaneous femoral and radial pulses

Lungs

Abdomen

Genitourinary (males only)b

Skin

• HSV, lesions suggestive of MRSA, tinea corporis

Neurologic c

MUSCULOSKELETAL

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand/fingers

Hip/thigh

Knee

Leg/ankle

Foot/toes

Functional

• Duck-walk, single leg hop

aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.bConsider GU exam if in private setting. Having third party present is recommended. cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

Cleared for all sports without restriction

Cleared for all sports without restriction with recommendations for further evaluation or treatment for _________________________________________________________________

____________________________________________________________________________________________________________________________________________

Not cleared

Pending further evaluation

For any sports

For certain sports _____________________________________________________________________________________________________________________

Reason ___________________________________________________________________________________________________________________________

Recommendations _________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and

participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If condi-

tions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely

explained to the athlete (and parents/guardians).

Name of physician, advanced practice nurse (APN), physician assistant (PA) (print/type)____________________________________________ Date of exam ________________

Address ________________________________________________________________________________________________________ Phone _________________________ Signature of physician, APN, PA _____________________________________________________________________________________________________________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic

Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.HE0503 9-2681/0410

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and

participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions

arise after the athlete has been cleared for participation, a physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained

to the athlete (and parents/guardians).


■■■ �Preparticipation�Physical�Evaluation��CLEARANCE�FORM

Name ___ ____________________________________________________ Sex M F Age _________________ Date of birth _________________

Cleared for all sports without restriction

Cleared for all sports without restriction with recommendations for further evaluation or treatment for _______________________________________________

___________________________________________________________________________________________________________________________

Not cleared

Pending further evaluation

For any sports

For certain sports _____________________________________________________________________________________________________

Reason ___________________________________________________________________________________________________________

Recommendations _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Name of physician, advanced practice nurse (APN), physician assistant (PA) ____________________________________________________ Date _______________

Address _________________________________________________________________________________________ Phone _________________________

Signature of physician, APN, PA _____________________________________________________________________________________________________

Completed Cardiac Assessment Professional Development Module

Date___________________________ Signature_______________________________________________________________________________________

EMERGENCY INFORMATION

Allergies ______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

Other information _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71

APPENDIX H UNIVERSAL

CHILD HEALTH RECORD

Endorsed by: American Academy of Pediatrics, New Jersey Chapter New Jersey Academy of Family Physicians New Jersey Department of Health

SECTION I - TO BE COMPLETED BY PARENT(S) Child’s Name (Last) (First)

Gender

Male Female Date of Birth

/ / Does Child Have Health Insurance?

Yes No If Yes, Name of Child's Health Insurance Carrier

Parent/Guardian Name

Home Telephone Number

( ) - Work Telephone/Cell Phone Number

( ) - Parent/Guardian Name

Home Telephone Number

( ) - Work Telephone/Cell Phone Number

( ) -

I give my consent for my child’s Health Care Provider and Child Care Provider/School Nurse to discuss the information on this form. Signature/Date

This form may be released to WIC.

Yes No

SECTION II - TO BE COMPLETED BY HEALTH CARE PROVIDER Date of Physical Examination: Results of physical examination normal? Yes No Abnormalities Noted:

Weight (must be taken within 30 days for WIC)

Height (must be taken within 30 days for WIC)

Head Circumference (if <2 Years)

Blood Pressure (if >3 Years)

IMMUNIZATIONS Immunization Record Attached

Date Next Immunization Due: MEDICAL CONDITIONS

Chronic Medical Conditions/Related Surgeries • List medical conditions/ongoing surgical

concerns:

None Special Care Plan Attached

Comments

Medications/Treatments • List medications/treatments:


Comments

Limitations to Physical Activity • List limitations/special considerations:


Comments

Special Equipment Needs • List items necessary for daily activities


Comments

Allergies/Sensitivities • List allergies:


Comments

Special Diet/Vitamin & Mineral Supplements • List dietary specifications:


Comments

Behavioral Issues/Mental Health Diagnosis • List behavioral/mental health issues/concerns:


Comments

Emergency Plans • List emergency plan that might be needed and

the sign/symptoms to watch for:


Comments

PREVENTIVE HEALTH SCREENINGS Type Screening Date Performed Record Value Type Screening Date Performed Note if Abnormal

Hgb/Hct Hearing Lead: Capillary Venous Vision TB (mm of Induration) Dental Other: Developmental Other: Scoliosis

I have examined the above student and reviewed his/her health history. It is my opinion that he/she is medically cleared to participate fully in all child care/school activities, including physical education and competitive contact sports, unless noted above.

Name of Health Care Provider (Print)

Health Care Provider Stamp:

Signature/Date

CH-14 OCT 17 Distribution: Original-Child Care Provider Copy-Parent/Guardian Copy-Health Care Provider

Instructions for Completing the Universal Child Health Record (CH-14)

Section 1 - Parent

Please have the parent/guardian complete the top section and sign the consent for the child care provider/school nurse to discuss any information on this form with the health care provider.

The WIC box needs to be checked only if this form is being sent to the WIC office. WIC is a supplemental nutrition program for Women, Infants and Children that provides nutritious foods, nutrition counseling, health care referrals and breast feeding support to income eligible families. For more information about WIC in your area call 1-800-328-3838.

Section 2 - Health Care Provider

1. Please enter the date of the physical exam that is being used to complete the form. Note significant abnormalities especially if the child needs treatment for that abnormality (e.g. creams for eczema; asthma medications for wheezing etc.) • Weight - Please note pounds vs. kilograms. If the

form is being used for WIC, the weight must have been taken within the last 30 days.

• Height - Please note inches vs. centimeters. If the form is being used for WIC, the height must have been taken within the last 30 days.

• Head Circumference - Only enter if the child is less than 2 years.

• Blood Pressure - Only enter if the child is 3 years or older.

2. Immunization - A copy of an immunization record may be copied and attached. If you need a blank form on which to enter the immunization dates, you can request a supply of Personal Immunization Record (IMM-9) cards from the New Jersey Department of Health, Vaccine Preventable Diseases Program at 609-826-4860. The Immunization record must be attached for the form to be valid. • “Date next immunization is due” is optional but helps

child care providers to assure that children in their care are up-to-date with immunizations.

3. Medical Conditions - Please list any ongoing medical conditions that might impact the child's health and well being in the child care or school setting.

a. Note any significant medical conditions or major surgical history. If the child has a complex medical condition, a special care plan should be completed and attached for any of the medical issue blocks that follow. A generic care plan (CH-15) can be downloaded at www.nj.gov/health/forms/ch-15.dot or pdf. Hard copies of the CH-15 can be requested from the Division of Family Health Services at 609-292-5666.

b. Medications - List any ongoing medications. Include any medications given at home if they might impact the child's health while in child care (seizure, cardiac or asthma medications, etc.). Short-term medications such as antibiotics do not need to be listed on this form. Long-term antibiotics such as antibiotics for urinary tract infections or sickle cell prophylaxis should be included.

PRN Medications are medications given only as needed and should have guidelines as to specific factors that should trigger medication administration.

Please be specific about what over-the-counter (OTC) medications you recommend, and include information for the parent and child care provider as to dosage, route, frequency, and possible side effects. Many child care providers may require separate permissions slips for prescription and OTC medications.

c. Limitations to physical activity - Please be as specific as possible and include dates of limitation as appropriate. Any limitation to field trips should be noted. Note any special considerations such as avoiding sun exposure or exposure to allergens. Potential severe reaction to insect stings should be noted. Special considerations such as back-only sleeping for infants should be noted.

d. Special Equipment – Enter if the child wears glasses, orthodontic devices, orthotics, or other special equipment. Children with complex equipment needs should have a care plan.

e. Allergies/Sensitivities - Children with life-threatening allergies should have a special care plan. Severe allergic reactions to animals or foods (wheezing etc.) should be noted. Pediatric asthma action plans can be obtained from The Pediatric Asthma Coalition of New Jersey at www.pacnj.org or by phone at 908-687-9340.

f. Special Diets - Any special diet and/or supplements that are medically indicated should be included. Exclusive breastfeeding should be noted.

g. Behavioral/Mental Health issues – Please note any significant behavioral problems or mental health diagnoses such as autism, breath holding, or ADHD.

h. Emergency Plans - May require a special care plan if interventions are complex. Be specific about signs and symptoms to watch for. Use simple language and avoid the use of complex medical terms.

4. Screening - This section is required for school, WIC, Head Start, child care settings, and some other programs. This section can provide valuable data for public heath personnel to track children's health. Please enter the date that the test was performed. Note if the test was abnormal or place an "N" if it was normal. • For lead screening state if the blood sample was

capillary or venous and the value of the test performed.

• For PPD enter millimeters of induration, and the date listed should be the date read. If a chest x-ray was done, record results.

• Scoliosis screenings are done biennially in the public schools beginning at age 10.

This form may be used for clearance for sports or physical education. As such, please check the box above the signature line and make any appropriate notations in the Limitation to Physical Activities block.

5. Please sign and date the form with the date the form was completed (note the date of the exam, if different) • Print the health care provider's name. • Stamp with health care site's name, address and

phone number.

CH-14 (Instructions) OCT 17

http://www.state.nj.us/health/forms/ch-15.dot

http://www.pacnj.org/

FORMULARIO DE SOLICITUD DE REGISTRO ACADEMICO

Fecha: ________________________________ El nifio nombrado a continuación se ha inscrito en una de nuestras escuelas. El padre / tutor ha autorizado que se envien los siguientes registros a la escuela que se encuentra dentro de un circulo lo antes posible: Academico (incluyendo boleta de calificaciones, expediente academico, puntajes de

examenes estandarizados, I.E.P.) Asistencia Disciplinario Medico / Salud Confidencial

Nombre completo de la escuela anterior: _____________________________________________________

Dirección: ______________________________________________________________

Código postal: __________________________________________________________

Teléfono no.: ___________________________________________________________

Número de fax: _________________________________________________________

Email de contacto: _______________________________________________________

Gracias por su cooperación.

Por la presente doy permiso para divulgar todos los registros académicos, de asistencia, de salud, disciplinarios y confidenciales de la escuela: El nombre del niño: ________________________________________________________

Nivel de grado actual: ____________________________

Nombre del padre / tutor (en letra de imprenta): __________________________________

Firma del Padre / Tutor: _____________________________________________________ 4/23/2020

Escuela Grant 104 Henry Street

201-641-0441

Escuela Lincoln 712 Lincoln Avenue

201-994-1830

Escuela Roosevelt 508 Teaneck Road

201-440-0808

RPJRSRHS One Ozzie Nelson Drive

201-440-1440

Oficina de Servicios Especials 98 Central Avenue

201-807-2650


(201) 807-2640 / www.rpps.net


INICIATIVA DE MEDICAID DE EDUCACION ESPECIAL (SEMI)

Formulario de consentimiento parental

Nuestro distrito escolar participa en el programa de Iniciativa de Medicaid para Educación Especial (SEMI, por sus siglas en de vista) que permite a los distritos escolares facturar a Medicaid por los servicios que se proporcionan a los estudiantes.

De acuerdo con la Ley de Derechos Educativos y Privacidad de la Familia, 34 CFR §99.30 y la Sección 617 de la Parte B de IDEA, los requisitos de consentimiento en 34 CFR §300.622 requieren un consentimiento único antes de acceder a los beneficios públicos.

Este consentimiento establece que la información de identificación personal de su hijo, como los registros de los estudiantes o la información sobre los servicios proporcionados a su hijo, incluidas las evaluaciones y los servicios según lo especificado en el Programa de Educación Individualizado (IEP) de su hijo (terapia ocupacional, fisioterapia, terapia del habla, consejería psicológica, audiología, enfermería y transporte especializado) puede ser revelada a Medicaid y al Departamento del Tesoro con el propósito de recibir el reembolso de Medicaid en el distrito escolar.

Como padre/tutor del niño mencionado a continuación doy permiso para divulgar información como se describe anteriormente, y entiendo y acepto que Medicaid puede acceder a los beneficios de mi hijo o de mi público o seguro público para pagar educación especial o servicios relacionados bajo la Parte 300 (servicios bajo la IDEA). Entiendo que el distrito escolar todavía está obligado a proporcionar servicios a mi hijo de conformidad con su IEP, independientemente de mi estado de elegibilidad de Medicaid o la voluntad de consentimiento para la facturación de SEMI.

Entiendo que la facturación de estos servicios por parte del distrito no afecta mi capacidad de acceder a estos servicios para mi hijo fuera del entorno escolar, ni será incurrido en ningún costo por parte de mi familia, incluidos copagos,, deducibles y pérdida de elegibilidad o impacto en los beneficios de por vida.

Nombre del niño: __________________________________________________________________________________________

Firma del padre/tutor:

___________________________________________________________________________________________

Doy mi consentimiento para facturar por SEMI: Si NO

Este consentimiento puede ser revocado en cualquier momento contactando al Administrador de Casos de su hijo, o al administrador de la escuela de su hijo, por escrito. 4/23/20


(201) 807-2640 / www.rpps.net


Home Language Survey - Spanish

Encuesta sobre el idioma que se habla en el hogar: Paso 1

Introducción Esta encuesta es el primero de tres pasos para identificar si un estudiante es elegible para ser

estudiante del idioma inglés (ELL).

Instrucciones Comience con la "Pregunta 1" y continúe hasta que termine la encuesta. Seleccione una respuesta para cada pregunta y siga las instrucciones. Cuando llegue a la decisión ("Pasar al proceso de revisión de registros" o "No pasar al proceso de revisión de registros"), la encuesta sobre el idioma del hogar quedará finalizada.

Información sobre el alumno Nombre del alumno: Fecha de nacimiento del alumno:

Dirección:

Ciudad: Estado: Código postal:

Teléfono:

Cuestionario Pregunta 1

¿Cuál fue el primer idioma que el alumno utilizó?

Otro idioma que no sea el inglés. Pase a la pregunta 2a.

Inglés. Pase a la pregunta 2b.

Pregunta 2a

En el hogar, ¿el alumno escucha o usa un

idioma que no sea el inglés más de la mitad del

tiempo?

Sí. Pase a la pregunta 7.

No. Pase a la pregunta 4.

Pregunta 2b

En el hogar, ¿el alumno escucha o usa un

idioma que no sea el inglés más de la mitad

del tiempo?



Pregunta 3

¿El alumno entiende un idioma que no sea el inglés?



Home Language Survey - Spanish

Pregunta 4

Cuando interactúa con sus padres o tutores, ¿el alumno usa otro idioma que no sea el inglés más

de la mitad del tiempo?



Pregunta 5

Cuando interactúa con otros cuidadores que no sean sus padres o tutores, ¿el alumno usa otro

idioma que no sea el inglés más de la mitad del tiempo?



Pregunta 6

¿El alumno se ha mudado recientemente de otro distrito escolar/escuela experimental donde se lo

identificó como estudiante del idioma inglés?



Pregunta 7

¿Cuáles son los idiomas que se hablan en el hogar? A continuación, haga una lista de estos idiomas

y pase a la pregunta 8.

8. Pase al paso 2: Proceso de revisión de registros (Para que

complete únicamente personal certificado de NJ – Referencias Guía de ingreso y egreso ESSA

ELL, p. 4). La encuesta sobre el idioma que se habla en el hogar está

completa.

9. No pase al paso 2: Proceso de revisión de registros. La encuesta sobre el idioma que se habla en el hogar está

completa. El alumno no es estudiante del idioma inglés (ELL).

https://www.state.nj.us/education/bilingual/policy/ESSAGuidance.pdf

https://www.state.nj.us/education/bilingual/policy/ESSAGuidance.pdf

RIDGEFIELD PARK PUBLIC SCHOOLS - SharpSchoolrpps.ss8.sharpschool.com/UserFiles/Servers/Server... ·...

Documents

Transcript of RIDGEFIELD PARK PUBLIC SCHOOLS - SharpSchoolrpps.ss8.sharpschool.com/UserFiles/Servers/Server... ·...